A urinary tract infection (UTI) during pregnancy occurs when bacteria enter the urinary tract, leading to an infection. This condition is relatively common during pregnancy due to hormonal changes that can affect the urinary system, as well as the physical changes that occur as the uterus expands and puts pressure on the bladder. UTIs in pregnancy require prompt attention and treatment to prevent complications for both the mother and the baby

1. • Immediate Past Chairperson ICOG –Indian College of
OB/GY
• National Corresponding Editor-Journal of OB/GY of
India JOGI
• National Corresponding Secretary-AMWI Association
of Medical Women, India
• President –ISOPARB Vidarbha Chapter 2019-21
• Chairperson-IMS Education Committee 2021-23
• Chairperson-fertility enhancement Committee-
ISOPARB
• Member-SAFOG Education Committee
• President-Association of Medical Women, Nagpur
AMWN 2021-24
• Senior Vice President FOGSI 2012
• President Menopause Society, Nagpur 2016-18
• President Nagpur OB/GY Society 2005-06
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra
 Nagpur Ratan Award @hands of
Union Minister Shri Nitinji
Gadkari
 Received Bharat excellence Award
for women’s health
 Received Mehroo Dara Hansotia
Best Committee Award for her
work as Chairperson HIV/AIDS
Committee, FOGSI 2007-2009
 Received appreciation letter from
Maharashtra Government for her
work in the field of SAVE THE
GIRL CHILD
 Delivered 22 orations and
450 guest lectures
 Publications- 42 National &
21 International
 Sensitized 2 lakh boys and
girls on adolescent health
issues
Awards
Positions

2. UTI in Pregnancy
Dr Laxmi Shrikhande
Senior Consultant- Shrikhande Fertility Clinic
Nagpur, Maharashtra

3. Definition of Urinary tract infection
UTI is defined as the presence of at least 100,000 organisms
per milliliter of urine in an asymptomatic patient, or as more
than 100 organisms/mL of urine with accompanying pyuria
(> 7 white blood cells [WBCs]/mL) in a symptomatic patient.
A diagnosis of UTI should be supported by a positive culture
for a uropathogen, particularly in patients with vague
symptoms.

5. Classification of UTI’s
Clinical:
• Asymptomatic (8%)
• Symptomatic (1-2%)
Anatomical:
• Lower tract : asymptomatic bacteriuria and acute cystitis
• Upper tract : acute pyelonephritis

6. Definition of Asymptomatic bacteriuria
Asymptomatic bacteriuria is commonly defined as the presence of
more than 100,000 organisms/mL in 2 consecutive urine samples in
the absence of declared symptoms.
Untreated asymptomatic bacteriuria is a risk factor for acute cystitis
(40%) and pyelonephritis (25-30%) in pregnancy.
This usually occurs in early pregnancy.
Risk factors include prior UTIs, pre-existing diabetes, increased parity,
and low socioeconomic status.

7. Definition of Cystitis
Acute cystitis involves only the lower urinary tract; it is characterized by
inflammation of the bladder as a result of bacterial or nonbacterial causes..
Acute cystitis develops in approximately 1- 2% of pregnant patients, of whom
60% have a negative result on initial screening.
Signs and symptoms include haematuria, dysuria, suprapubic discomfort,
frequency, urgency, and nocturia.
These symptoms are often difficult to distinguish from those due to pregnancy
itself.
Acute cystitis is complicated by upper urinary tract disease (ie, pyelonephritis) in
15-50% of cases.

8. Acute pyelonephritis
Pyelonephritis is the most common urinary tract
complication in pregnant women, occurring in approximately
0.5-2% of all pregnancies.
 Acute pyelonephritis is characterized by fever, flank pain,
and tenderness in addition to significant bacteriuria.
Other symptoms may include nausea, vomiting, frequency,
urgency, and dysuria.
 Most cases of pyelonephritis occur in the second and third
trimester.

9. Types of UTI Recurrences
Relapse: same organism within 2-3 wks
secondary to perineal colonization or inadequate Rx
Reinfection: new organism within 12 wks
2ndry to recurrent bladder bacteriuria
Superinfection: new organism while on Rx
Prevention:
Prenatal screening for ASB in pregnant women

11. Etiology
 E coli is the most common cause of UTI, accounting for approximately 70-80% of cases in
pregnancy. It originates from fecal flora colonizing the periurethral area, causing an ascending
infection. Other pathogens include the following :
 Klebsiella pneumoniae (5%)
 Proteus mirabilis (5%)
 Enterobacter species (3%)
 Staphylococcus saprophyticus (3%)
 Group B beta-hemolytic Streptococcus (GBS; 2-5%)
 Proteus species (2%)

12. The differential diagnosis of UTI in pregnancy :
 Cervicitis
 Chlamydial Genitourinary Infections
 Nonbacterial and Noninfectious Cystitis
 Ectopic Pregnancy
 Interstitial Cystitis
 Nephrolithiasis
 Trichomoniasis
 Trigonitis
 Urethritis
 Vaginitis
Vaginal infections can cause or mimic UTIs, which are common in women of reproductive age, affecting 25-35% of women aged
20-40 years. Discriminating between the 2 depends on the results of vaginal and urinary cultures.

13. Clinical Presentation-History
The presentation varies according to whether the patient has asymptomatic
bacteriuria, a lower urinary tract infection (UTI; ie, cystitis) or an upper UTI (ie,
pyelonephritis).
Burning with urination (dysuria) is the most significant symptom in pregnant
women with symptomatic cystitis.
Other symptoms include frequency, urgency, suprapubic pain, hematuria, and
pyuria in the absence of systemic symptoms.
The usual complaints of increased frequency, nocturia, and suprapubic pressure
are not particularly helpful, because most pregnant women experience these as a
result of increased pressure from the growing uterus, expanding blood volume,
increased glomerular filtration rate, and increased renal blood flow.
Pyelonephritis signs and symptoms often include fever (> 38°C), shaking chills,
anorexia, nausea, vomiting, and costovertebral angle tenderness.

14. Physical Examination
 Physical examination findings should be considered in relation to the duration of pregnancy.
 The differential diagnoses may change from one trimester to the next, and the increasing size of the
gravid uterus may mask or mimic disease findings.
 A thorough physical examination is recommended, with particular attention to the abdomen.
 Suprapubic or costovertebral tenderness may be present.
 In asymptomatic bacteriuria, no physical findings are typically present. Symptoms may arise
intermittently, only to be overlooked because of lack of persistence or severity.
 Pelvic examination is recommended in all symptomatic patients (with the exception of third-trimester
patients with bleeding) to rule out vaginitis or cervicitis. In patients with cystitis, tenderness can
often be elicited with isolation of the bladder on pelvic examination.
 Patients with pyelonephritis have fever (usually > 38°C), flank tenderness upon palpation, and an ill
appearance. Flank tenderness occurs on the right side more frequently, and is present in more than
half of patients. Pain may also be found suprapubically with palpation.
 Assessment of the fetal heart rate on the basis of gestational age should be included as part of the
evaluation. Often, owing to maternal fever, the fetal heart rate is elevated to more than 160
beats/min.

15. Workup
Laboratory studies can include blood studies and urine
studies, including culture, urinalysis, dipstick testing, and
other tests (eg, urine cytology, sulfosalicylic acid [SSA]
testing).
Imaging tests can include ultrasonography and intravenous
pyelography.

16. Blood Studies
 The following blood tests should be ordered at the physician’s discretion, though the results do not
aid in the diagnosis or change treatment unless they are markedly abnormal:
 Complete blood count (CBC)
 Serum electrolytes
 Blood urea nitrogen (BUN)
 Serum creatinine
 In pregnant women who are showing signs of sepsis, it is reasonable to obtain blood cultures and a
lactic acid assay.
 Although there is no evidence that positive blood cultures are associated with worse prognosis,
elevated lactic acid levels have been associated with adverse maternal outcomes in presumed
sepsis.

17. Urine culture
 Urine culture is the standard method for evaluating for urinary tract infection (UTI) during pregnancy.
Indications for performing a urine culture include the following:
 New onset of symptoms of cystitis with positive urinalysis or dipstick testing
 Recurrent UTI
 Pyelonephritis
 Failure to respond to initial treatment regimens
 History of recent instrumentation
 Hospital admission
 A voided specimen with a bacterial growth of 100,000 colony-forming units (CFUs) per milliliter or
higher is the standard definition of a positive urine culture. Counts lower than 100,000 CFU/mL
usually indicate specimen contamination rather than infection. Patients with pyelonephritis often
have white blood cell (WBC) casts.
 Culture results can be used to identify specific organisms and antibiotic sensitivities, but results are often
unavailable at the time of treatment.

18. Urinalysis by microscopy
 Positive results for nitrites, leukocyte esterase, WBCs (pyuria), red blood cells (RBCs), and protein
suggest UTI.
 Pyuria is present in almost all women with cystitis.
 Bacteria found in the specimen can help with the diagnosis.
 The presence of bacteria without pyuria usually represents contamination of the urine.
 Urinalysis has a specificity of 97-100%, but it has a sensitivity of only 25-67% when compared with
culture in the diagnosis of asymptomatic bacteriuria.
 Clumping WBCs and WBC casts are indicative of kidney inflammation and are consistent with
upper tract infection or pyelonephritis.
 RBC casts are characteristic of acute glomerulonephritis, which should be suspected after a recent
or concurrent streptococcal infection.
 Renal involvement usually leads to proteinuria.
 Nephrotic syndrome includes high proteinuria (> 3.5 g/24 h), edema, hypercholesterolemia, and
hypoalbuminemia; however, this can be confused with preeclampsia.
 Oval fat bodies and fatty casts can suggest membranous glomerulonephritis.

19. Dipstick testing
 Several reports describe the use of urine dip for nitrites and leukocyte esterase in the evaluation of
asymptomatic bacteriuria.
 In comparison with culture, sensitivity ranges from 50% to 92% and specificity from 86% to 97%.
 In the evaluation of symptomatic patients, dipstick testing is useful and inexpensive.
 However, the leukocyte esterase test may be unreliable in patients with low-level pyuria (5-20
WBCs/HPF).
 The addition of protein and blood increases the sensitivity and specificity of the test in the
evaluation of UTI.
 A positive nitrite test is reliable for bacteriuria, but a negative test does not exclude bacteriuria.
 The reason for this is that bacteria converts the dietary metabolite nitrate to nitrite in the urine.
 As suggested by Kodikara et al, nitrite dipstick testing may be a reasonable and cost-effective
screening strategy for women who otherwise may not undergo screening for bacteriuria, as is often
the case in developing countries.

20. Renal Ultrasonography and Intravenous Pyelography
 Unless an anatomic abnormality or renal disease is suspected, initial routine imaging studies are not
necessary.
 Patients with suspected pyelonephritis who are not responsive to appropriate antibiotic therapy after 48-
72 hours should undergo imaging.
 In pregnant patients, the recommended imaging study to perform first is a renal ultrasound, to avoid
contrast and radiation unless necessary.
 Renal ultrasound is helpful to visualize kidney or ureteral stones, renal abscess formation, or
hydronephrosis.
 Renal ultrasonography (or limited intravenous pyelography [IVP] if the benefits of a definitive diagnosis
outweigh the minor risk of radiation) may be helpful in patients with recurrent urinary tract infection (UTI)
or symptoms that suggest nephrolithiasis .
 Confusion about the diagnosis of urolithiasis, pyelonephritis, or both is an indication for obtaining imaging
studies.

21. Treatment of bacteriuria and cystitis
 Because of the dangers of maternal and fetal complications, acute care should focus on identifying
and treating asymptomatic and symptomatic bacteriuria, along with ensuring that an alternative
process is not the cause of the symptoms.
 Treatment of asymptomatic bacteriuria has been shown to reduce the incidence of low birth weight
and preterm birth.
Behavioral practices
 Any discussion of treatment should be prefaced with a discussion of behaviors that may be used to
ensure good hygiene and reduce bacterial contamination of the urethral meatus, thereby preventing
inadequate treatment and recurrent infection. Behavioral methods include the following:
 Wipe front-to-back after urinating or defecating
 Wash hands before using the toilet
 Use washcloths to clean the perineum
 Use liquid soap to prevent colonization from bar soap
 Clean the urethral meatus first when bathing

22. Antibiotic therapy
Oral antibiotics are the treatment of choice for asymptomatic
bacteriuria and cystitis.
Treatment is most commonly initiated empirically before culture
and susceptibility results return.

23. Treatment Regimens for Pregnant Women with
Asymptomatic Bacteriuria or UTI
Nitrofurantoin monohydrate/macrocrystals 100 mg orally twice daily
for 5-7 days or
Amoxicillin 875 mg orally twice daily (alternative: 500 mg orally three
times daily) for 5-7 days or
Amoxicillin-clavulanate 500/125 mg orally three times daily for 5-7
days (alternative: 875/125 mg orally two times daily for 5-7 days) or
Cephalexin 500 mg orally four times daily for 5-7 days or
Fosfomycin 3 g orally as a single dose with 3-4 oz. of water

24. Antibiotic therapy
Although 1-, 3-, and 7-day antibiotic courses have been
evaluated, 10-14 days of treatment is usually recommended to
eradicate the offending bacteria.
Treatment success depends on eradication of the bacteria
rather than on the duration of therapy.
 A test-for-cure urine culture should show negative findings 1-2
weeks after completion of therapy.
A nonnegative culture result is an indication for a 10- to 14-day
course of a different antibiotic.

25. Antibiotic therapy
Recurrent cystitis
Pregnant women who have three or more episodes of cystitis or
bacteriuria should be started on daily antibiotic prophylaxis for the
remainder of pregnancy.
Daily antibiotics should also be considered in pregnant women after one
episode of pyelonephritis.
 Regimens for daily prophylaxis includes nitrofurantoin 100 mg nightly, or
cephalexin 250-500 mg nightly.
In patients who are immunosuppressed or have medical conditions that
would increase the risk of complications from cystitis, it is reasonable to
consider antibiotic prophylaxis after one episode of cystitis.

26. Treatment of pyelonephritis
The standard course of treatment for pyelonephritis consists of hospital
admission and intravenous (IV) administration of antibiotics until the
patient has been afebrile for 48 hours.
The recommended IV antibiotic would be a broad spectrum beta-lactam,
such as ceftriaxone.
Once culture results with susceptibilities become available and the patient
is clinically improved, treatment can be transitioned to an oral antibiotic
regimen.
 For women with a history of extended-spectrum beta-lactamase (ESBL)
Enterobacter, a carbapenem is recommended.
Patients should be discharged with 10-14 days of antibiotic treatment, and
then will need daily prophylactic antibiotics for the remainder of
pregnancy.

27. Treatment of pyelonephritis
IV fluids must be administered with caution.
Patients with pyelonephritis can become dehydrated because of nausea and
vomiting and need IV hydration, but they are at high risk for the development of
pulmonary edema and acute respiratory distress syndrome (ARDS).
Fever should be managed with antipyretics (preferably, acetaminophen) and
nausea and vomiting with antiemetics.
 If fever persists beyond 24 hours, urine and blood cultures should be repeated
and a renal ultrasound should be performed.
Preterm labor and delivery are additional risks associated with pyelonephritis.
 These risks must be evaluated and treated early in the course of admission with
tocolysis as necessary per the preterm labor guidelines.
If the patient is septic, tocolysis is not recommended.

28. Surgical treatment
Surgical care is rarely indicated.
Cystoscopy may aid in establishing the diagnosis of urethral or bladder diverticulum,
bladder stones, urethral syndrome, lower urinary tract trauma, interstitial cystitis, or
bladder cancer.
A retrograde stent or a percutaneous nephrostomy tube should be placed to relieve
ureteral colic or decompress an obstructed infected collecting system.
More invasive procedures, such as ureteroscopic stone extraction, are rarely indicated.
 Extracorporeal shock wave lithotripsy (ESWL) is contraindicated in pregnancy.
In the rare patient for whom invasive surgical therapy is indicated, the operation should be
planned for the second trimester.
Surgical intervention during the first trimester is associated with increased risk of
miscarriage; surgery in the third trimester is associated with increased risk of preterm
labor.
Urgent surgical intervention in the third trimester should coincide with delivery of the fetus.

29. Obstetric management —
 Pyelonephritis is not itself an indication for delivery.
 If induction of labor or cesarean delivery for standard obstetrical indications is planned in a patient
on treatment for pyelonephritis, wait until the patient is afebrile, as long as delaying the delivery is
relatively safe for the mother and fetus.
 Since pyelonephritis is associated with preterm birth, an important obstetric consideration is
whether tocolysis should be used when pyelonephritis triggers preterm labor at various gestational
ages.
 Tocolysis is typically not administered after 34 weeks gestation.
 If a woman with pyelonephritis prior to that gestational age experiences preterm labor,
administration of tocolysis and steroids is reasonable to attempt to prolong the pregnancy.
 However, if the patient is septic, tocolysis is generally avoided.
 Pregnant women with pyelonephritis are at increased risk of pulmonary edema and acute
respiratory distress syndrome (ARDS), which may be exacerbated by administration of tocolysis with
or without corticosteroids.

30. Preventing recurrence —
Recurrent pyelonephritis during pregnancy occurs in 6 to 8 percent of women .
As a result, after an initial episode of pyelonephritis, low-dose antimicrobial preventive
therapy with an agent to which the original organism is susceptible for the remainder of
the pregnancy is a reasonable strategy; but there are no randomized trials to inform the
optimal approach.
 If preventive therapy is utilized, reasonable options include nitrofurantoin (50 to 100 mg
orally at bedtime) or cephalexin (250 to 500 mg orally at bedtime) .
For individuals who use preventive antibiotics following pyelonephritis, do not perform
surveillance urine cultures to ensure effective prophylaxis.

31. Prevention in women with history of recurrent UTI
A separate issue is the management of pregnant women with a history of
recurrent urinary tract infections (UTIs) prior to pregnancy, which is often
related to sexual intercourse.
 It is reasonable to use postcoital prophylaxis in pregnant women who
have recurrent UTIs that appear to be temporally related to sexual
intercourse.
The preferred regimen is a single postcoital dose of either cephalexin (250
mg) or nitrofurantoin (50 mg).

32. Antibiotic safety in pregnancy
Penicillins (with or without beta-lactamase inhibitors), cephalosporins, the
carbapenems meropenem and ertapenem, aztreonam, and fosfomycin are generally
considered safe in pregnancy .
Nitrofurantoin is typically avoided during the first trimester because of uncertain
associations with congenital anomalies , although overall evidence suggests it is a
reasonable alternative during this period if other options cannot be used.
Trimethoprim-sulfamethoxazole is also often avoided during the first trimester because of
a potential association with congenital abnormalities and near term because of a
theoretical risk of kernicterus ; however, it remains a reasonable alternative during these
periods given the uncertainty of the evidence if other options cannot be used.

33. Antibiotic safety in pregnancy
 Aminoglycosides have been associated with ototoxicity following prolonged fetal exposure ,
and fluoroquinolones are generally not used during pregnancy.
 Much of the information regarding the safe use of antibiotics during pregnancy was obtained
decades ago, before pregnant women were excluded from drug studies because of concerns
about risk to the fetus.
 Thus, there is little direct information about the safety of many newer antibiotics (including
many antibiotics that are used for UTI) in pregnancy, and concern about the use of certain
antibiotics generally arises from indirect evidence (eg, animal studies) or observational studies
that may have numerous confounders.
 Overall, the safest course is to use the antibiotics that have well-established safety profiles in
pregnancy and limit the use of antibiotics of potential concern to cases in which no safer
alternative exists.

34. Complications
 The primary complication of bacteriuria during pregnancy is cystitis, though the primary morbidity is due to pyelonephritis.
Complications may include the following:
 Perinephric cellulitis and abscess
 Septic shock
 Renal dysfunction (usually transient, but as many as 25% of pregnant women with pyelonephritis have a decreased glomerular
filtration rate)
 Hematologic dysfunction, including anemia or thrombocytopenia
 Hypoxic fetal events due to maternal complications of infection that lead to hypoperfusion of the placenta
 Preeclampsia
 Preterm labor, and possible subsequent preterm delivery, leading to increased infant morbidity and mortality
 Pregnant women with pyelonephritis can become critically ill very quickly. It has been estimated that approximately 20% of
pregnant women with severe pyelonephritis develop complications that include septic shock variants.
 Pulmonary injury may also complicate UTI in pregnancy. Approximately 2% of women with severe pyelonephritis during
pregnancy have evidence of pulmonary injury due to systemic inflammatory response syndrome and respiratory insufficiency.
Endotoxins that alter alveolar-capillary membrane permeability are produced; subsequently, pulmonary edema and acute
respiratory distress syndrome develop.

35. Prognosis
In most cases of bacteriuria and urinary tract infection (UTI) in pregnancy,
the prognosis is excellent.
Maternal UTI has few direct fetal sequelae because fetal bloodstream
infection is rare; however, uterine hypoperfusion due to maternal
dehydration, maternal anemia, and direct bacterial endotoxin damage to
the placental vasculature may cause fetal cerebral hypoperfusion.
Untreated upper UTIs are associated with low birth weight,
prematurity, premature labor, hypertension, preeclampsia, maternal
anemia, and amnionitis.
Preeclampsia- A meta-analysis of 19 studies demonstrated an increased
odds (1.31-fold) of preeclampsia in women with any UTI during pregnancy
versus those without UTI.

36. Summary and recommendations
Asymptomatic bacteriuria
• Screening – Screen all pregnant women at least once for asymptomatic bacteriuria.
Screening for asymptomatic bacteriuria is performed at 12 to 16 weeks gestation with a
midstream urine for culture. The diagnosis is made by finding high-level bacterial growth
(≥105 colony-forming units [cfu]/mL) on urine culture in the absence of symptoms
consistent with UTI.
• Management – Management of asymptomatic bacteriuria in pregnant women includes
antibiotic therapy tailored to culture results, which reduces the risk of subsequent
pyelonephritis and is associated with improved pregnancy outcomes. Potential options
include beta-lactams, nitrofurantoin, and fosfomycin . Do not routinely perform follow-up
culture to rescreen for asymptomatic bacteriuria.

37. Summary and recommendations
Cystitis (bladder infection) – Acute cystitis should be suspected in pregnant
women who complain about new onset dysuria, frequency, or urgency.
The diagnosis is made by finding of bacterial growth on urine culture in
this setting.
 Management of acute cystitis in pregnant women includes empiric
antibiotic therapy that is subsequently tailored to culture results.
Potential options for empiric and directed therapy include beta-
lactams, nitrofurantoin, and fosfomycin .
Do not routinely perform follow-up culture to confirm sterilization of the
urine.
For those with recurrent cystitis, prophylactic or suppressive antibiotics
may be warranted in addition to retreatment.

38. Summary and recommendations
• Pyelonephritis
• Clinical features and diagnosis – Acute pyelonephritis during pregnancy is suggested by
the presence of flank pain, nausea/vomiting, fever (>38°C), and/or costovertebral angle
tenderness, with or without the typical symptoms of cystitis, and is confirmed by the
finding of bacteriuria in the setting of these symptoms.
• Pregnant women may become quite ill and are at risk for both medical (eg, sepsis,
respiratory failure) and obstetrical complications from pyelonephritis.
• Management – Management of acute pyelonephritis in pregnant women includes hospital
admission for parenteral antibiotics, preferably broad spectrum beta-lactams .
• Antibiotic therapy can be converted to an oral regimen tailored to the susceptibility profile of the
isolated organism following clinical improvement. Oral options are generally limited to beta-lactams
or, if in the second trimester, trimethoprim-sulfamethoxazole. Following the treatment course,
preventive antibiotics are a reasonable strategy for the remainder of the pregnancy to prevent
recurrence.

39. Summary and recommendations
• Antibiotic safety – It is generally accepted that penicillins (with or without
beta-lactamase inhibitors), cephalosporins, aztreonam, and fosfomycin are
safe in pregnancy.
• Because of possible but uncertain associations with adverse birth
outcomes, avoid nitrofurantoin during the first trimester
and trimethoprim-sulfamethoxazole during the first trimester and near
term, but they are appropriate alternatives during those periods if other
options cannot be used.

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